Leonard S. Sommer

Anomalous coronary arteries: angiographic findings in 80 patients

Among 13010 adults who underwent coronary arteriography, 80 (0.61%) patients had a total of 83 anomalous coronary arteries. Thirty-three (41%) of the patients were of Hispanic origin, while out of the entire population studied 30% were Hispanic. The right coronary artery was the most common anomalous vessel. It was identified in 50 (62%) patients, arising in 35 from the left aortic sinus, in 14 from the posterior sinus, and in 1 from the left coronary artery. An anomalous circumflex artery was recognized in 22 (27%) patients. Nine (11%) patients presented an anomalous left anterior descending artery, 1 patient an anomalous left main coronary artery, and another an anomalous septal perforator artery. Twenty-three (29%) patients had concomitant congenital heart abnormalities, most commonly. bicuspid aortic valve and mitral valve prolapse. In each of 5 patients with complex congenital heart disease the course of the anomalous vessel could have interfered with a surgical procedure. In 4 cases anomalous coronary arteries were associated with either anomalous systemic venous circulation or anomalous cardiac veins. In 5 (6%) patients only, the anomalous coronary artery was solely responsible for a clinical event. Coronary atherosclerosis of the anomalous arteries was found in 28% of the patients, while the overall incidence of the disease in this series was 65%. Thus, anomalous coronary arteries are associated with a high incidence of congenital heart diseases, but do not appear to be associated with an increased risk for development of coronary atherosclerosis. The angiographic recognition of these vessels is important in patients who undergo coronary angioplasty or cardiac surgery. Variations in the frequency of congenital coronary anomalies as reported herein may be attributed to a genetic background.

Myocardial infarction due to congenital coronary arterial aneurysm (with successful saphenous vein bypass graft)

Abstract A 32 year old white woman with congenital saccular aneurysm of the left coronary artery is described. The patient presented with acute myocardial infarction. Calcification in the wall of the aneurysm could be seen on the chest roentgenogram. Selective coronary cineangiograms demonstrated a calcified aneurysm at the origin of the left anterior descending coronary artery which caused complete occlusion of this vessel and partial compression of the circumflex coronary artery. Left ventricular cineangiograms disclosed an akinetic area in the anterior wall and mild mitral regurgitation. The patient successfully underwent saphenous vein bypass graft from aorta to left anterior descending coronary artery. Postoperative studies demonstrated patency of the vein graft with excellent antegrade filling of a normal vessel and nonfunctioning of the previously demonstrated collateral channels.

Hemodynamic features of prolapsing and nonprolapsing left atrial myxoma.

In the course of the evaluation of five patients with left atrial myxoma, it was noted that the movement of the myxoma was related to specific changes in left atrial hemodynamics. Prolapsing tumors, Type I, move from the left ventricle to the left atrium in early systole and from the left atrium to the left ventricle in early diastole, thereby causing prominent c and v waves accompanied by a rapid y descent. Nonprolapsing tumors, Type II, remain in the left atrium during the entire cardiac cycle, impeding flow across the mitral valve. In these latter cases, the y descent is slow and indistinguishable from that caused by mitral valvular stenosis. The cineangiocardiograms and echocardiograms corroborate these two types of hemodynamic observations. The particular value of direct echocardiographic examination of the left atrium prior to cardiac catheterization was evident in two of the three patients with nonprolapsing tumors. Since the hemodynamic pattern of nonprolapsing left atrial myxoma resembles that of mitral valvular stenosis, it is stressed that echocardiography should have an important place in precatheterization assessment of patients with mitral valve disease. If left atrial myxoma is suspected clinically or on the basis of echocardiographic findings, regardless of the pressure curve contours, transseptal cardiac catheterization should be avoided and the left atrium visualized by pulmonary angiography levophase.

Left atrial myxoma: Hemodynamic and phonocardiographic features

Abstract Two cases of left atrial myxoma are presented, with a review of clinical clues which may help in distinguishing this disease from mitral valve disease. Suggestive features in the apexcardiogram and internal and external phonocardiograms are discussed, together with related hemodynamic events indicated on the pulmonary capillary wedge, left atrial and left ventricular pressure tracings. The origins of various auscultatory features are analyzed in the light of specific hemodynamic events. Hemolytic anemia was present in one case, and ruptured chordae tendineae with scarring and myxomatous degeneration of the mitral leaflets in the other. Possible mechanisms for these lesions related to myxoma are discussed. The role of cardiac fluoroscopy, left ventricular cineangiography and the levophase of pulmonary angiography in helping to delineate left atrial myxoma is also mentioned.

Case reportLeft atrial myxoma: Hemodynamic and phonocardiographic features

Abstract Two cases of left atrial myxoma are presented, with a review of clinical clues which may help in distinguishing this disease from mitral valve disease. Suggestive features in the apexcardiogram and internal and external phonocardiograms are discussed, together with related hemodynamic events indicated on the pulmonary capillary wedge, left atrial and left ventricular pressure tracings. The origins of various auscultatory features are analyzed in the light of specific hemodynamic events. Hemolytic anemia was present in one case, and ruptured chordae tendineae with scarring and myxomatous degeneration of the mitral leaflets in the other. Possible mechanisms for these lesions related to myxoma are discussed. The role of cardiac fluoroscopy, left ventricular cineangiography and the levophase of pulmonary angiography in helping to delineate left atrial myxoma is also mentioned.

Depression of intramyocardial oxyhemoglobin dissociation by angiographic contrast media

The effect of the addition of radiographic contrast material (Renografin) to blood on the oxyhemoglobin dissociation curve and P50 was measured by a metabolic deoxygenation technique in a strongly buffered red cell suspension. With incubation time constant, increasing doses produced progressive decreases in P50. With incubation time varied at a constant dose, a decrease in P50 was seen after only one minute. In addition, in vivo studies were performed on 11 patients undergoing cardiac catheterization. Simultaneous proximal coronary sinus and aortic samples were drawn as controls, and then at one minute and five minutes after injection of the left coronary artery. In eight patients studies were performed after, and in three prior to left ventriculography. At one minute after left coronary injection there was a significant decrease of coronary sinus as compared to aortic P50 (p less than .10) (only when left ventriculography was performed prior to coronary arteriography). The magnitude of these effects in vivo is unknown, but they would be expected to be more severe in areas distal to a critical coronary lesion due to stasis of blood flow and ischemic metabolic changes.

His bundle recordings in bradycardia-dependent AV block induced by premature beats.

Symptomatic bradycardia-independent atrioventricular block occurred in a patient with right bundle-branch block, left anterior hemiblock, and prolonged HV interval. The arrhythmia, triggered by a spontaneous or induced premature beats, appeared when the post-extrasystolic PP and HH intervals increased to a critical value. Reinitiation of atrioventricular conduction required the presence of ventricular escapes. Bradycardia-dependent atrioventricular block was related to either an enhanced or slightly rising slope of diastolic depolarization, or to a decrease in membrane responsiveness. The patient also, most probably, had tachycardia-dependent atrioventricular block. Both types of conduction disturbance occurred in the same part of the intraventricular conducting system, either in the low His bundle or left bundle-branch or its posteroinferior division. It is suggested that the electrophysiological study of cases with prolonged HV intervals should include procedures which can expose bradycardia-dependent atrioventricular block.

Complications of Coronary Bypass Surgery

In the past three years, among 170 patients undergoing aortocoronary bypass surgery, 11 (6%) developed acute myocardial infarction within 24 hours after surgery. An additional four patients (2%) developed myocardial infarction within three months after discharge. Clinically, acute myocardial infarction was suspected because of sudden, transient hypotension associated with dysrhythmia, angina, or cardiac arrest which responded to conventional therapy. Elevation of serum enzymes with acute ECG changes was also observed. Three of the 15 patients developing myocardial infarction died. In 12 patients cardiac catheterization studies were performed within two to ten weeks after the incident. Eleven of the 20 grafts were found occluded, and progression of coronary occlusive disease was seen in five. There was a marked decrease in left ventricular function, contractility, and compliance in all patients with left ventricular aneurysm formation or dyskinesia. Eight of these patients were asymptomatic. The results indicate that after coronary surgery a combination of sudden arrhythmia and transient hypotension is diagnostic of graft closure or development of acute myocardial infarction. Also, in spite of depressed cardiac function, most surviving patients remain angina free.

Dislodgment of a bullet from the sinus of Valsalva by cardiac catheterization

Abstract The proper management of a patient with a retained intracardiac foreign body depends upon its precise localization and the accurate assessment of resulting cardiac damage. Cardiac catheterization with selective angiocardiographic studies provides a means for identifying both the exact location of the foreign body and the mechanism and extent of any cardiac dysfunction, including trauma to a coronary artery. In addition, the case reported documents the dislodgment of a bullet from the sinus of a coronary cusp by cardiac catheterization.

140 THE TRIAD OF COMPLETE HEART BLOCK, ABSENCE OF THE ATRIAL SEPTUM AND CONGENITAL INTERRUPTION OF THE IN FERIOR VENA CAVA

The association of complete heart block (CHB) and interruption of the inferior vena cava (IIVC) has not been previously emphasized. We analyzed the records of 29 patients (pts), age 1 day to 48 years, with angiographic documentation of IIVC with azygos continuation to a right or left superior vena cava. 28/29 pts had an associated intracardiac malformation, most common was an endocardial cushion defect (ECD). 76% (22/29) had a superiorly oriented P wave vector. CHB on surface ECG, with a QRS duration of <.08 msec, occurred in 24% (7/29 patients). In 4, CHB was congenital, diagnosed in-utero or early after birth, while 3 pts acquired the CHB during the natural progress of their disease. Each of these 7 pts had an ECD with complete absence of the atrial septum. The 4 patients with congenital CHB died hours or days after standard medical or surgical treatment and permanent pacemaker implantation. The 3 with acquired CHB are alive with permanent pacemaker implant, and two have had complete repair of their intracardiac lesion. In conclusion, 1) IIVC should be suspected in pts with superiorly oriented P wave vector on surface ECG; 2) In pts with CHB, IIVC, and abnormal atrial activation, absence of atrial septum should be suspected (100%); 3) the prognosis is poor if congenital CHB is present.